Sunday, February 28, 2010

Misusing technology in an IVF clinic - high tech mumbo jumbo and hocus pocus

My blood often boils when I see how technology is misused in many leading IVF clinics. It's a long list - and the variety is mind-boggling !

Reproductive Immunology tests include tests for NK cells and other complex and expensive tests, which are difficult to standardise and impossible to interpret - but very profitable to order ! Many doctors will send the samples to labs in the US, to ensure the results are "reliable" ! This just adds to the cost - and the mystique !

PCR tests for TB. Going by the large number of positive PCR tests for endometrial TB ( ordered by gynecologists) I see daily, there must be a virtual epidemic of genital TB in India ! These tests are all rubbish - but continue to be ordered . A positive result often means the patient has to endure 9 months of toxic antiTB chemotherapy for no rhyme a reason. Often this is such a traumatic experience, that most patients just decide never to have a baby at all !

Sperm DNA fragmentation tests. This is one of those tests which no one can make sense of. They are fun to order and expensive to perform - but give little useful information for the individual patient. Many fertile men also have high abnormal sperm DNA fragmentation levels !

Using FISH to check the sperm DNA . This is a test of no clinical utility - but will be used to convince patients that their sperm are "genetically abnormal" !

Karyotype for chromosomal studies. Minor anatomic variants ( such as an elongated arm on a chromosome) are often "blamed" for reproductive losses and IVF failures and patients are pushed to using donor eggs or doing PGD based on these "abnormalities" !

PGD is used to test embryos which have arrested in the IVF lab. We already know that even normal fertile women will have many genetically abnormal eggs which create genetically abnormal embryos. These are common and are often because of random genetic segregation . By doing the PGD,the doctor can charge a bomb for the test - and then explain to the patient that the reason they are not getting pregnant is because their embryos are genetically abnormal !

Based on the " abnormal results" of all these genetic tests, the doctor can than show the patient that the reason for the IVF failure is a genetic problem in the patient - and that they need donor egg treatment - which becomes even more expensive ( and much more profitable for the doctor !)

While some of these tests are fine as research tools , it's not acceptable to use these for clinical practise. Then why do some doctors use them routinely ?

Doctors often do this to generate revenue - the more the tests they order, the more they earn ! However, there are other reasons as well !

Infertility specialists are often highly competitive- and some of them play games to score points over the "competition" ! Often these tests are used to impress clueless patients as to how thorough and complete their clinic's evaluation is - and how much smarter and better equipped they are than the earlier IVF clinic the patient went
to , which did not bother to order these tests . Most patients are awed by medical technology which they do not understand, and many feel that more tests = more care = better care. In reality, more tests = more expense = more confusion !

Also, doing these esoteric ( and very expensive !) tests helps to put patients in their place . Instead of being honest with the patient and telling them that we often do not know precisely why they are infertile or why their IVF cycles fail, these tests allow the doctor to put on an aura of omniscience, and by using medical jargon and scientific mumbo-jumbo, re-emphasise the fact that the IVF doctor is the real expert and the patient needs to just leave everything in his expert hands !

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